Virtual Mentor. May 2004, Volume 6, Number 5.

doi: 10.1001/virtualmentor.2004.6.5.ccas2-0405

Clinical Cases

Disaster Triage
Triage duties in the event of a medical disaster have different ethical rules
than normal situations.
Commentary by James F. Childress, PhD

Several simultaneous explosions have occurred at an indoor stadium packed with eager fans during the third quarter of
a championship basketball game. Initial reports from eyewitnesses indicate that the detonated devices released a gas
throughout the stadium, which quickly overwhelmed the crowd and sparked panic. An unknown number of people
were severely injured or killed in the stampede to exit the stadium. Paramedics at the scene report that, to varying
degrees, the individuals affected by the gas have respiratory distress, muscle fasiculations, vomiting, and convulsions.
Several have been noted to have pinpoint pupils. No one is yet sure, but all signs indicate that a anticholinesterase
nerve agent was released inside the stadium.

Rebecca, a senior emergency medicine resident at the hospital closest to the stadium, is working intensely to see the
first few patients coming into her emergency room from the game. She is working with the staff to control patients'
convulsions, administer atropine, and intubate and ventilate patients when necessary. She becomes nervous as the
crowd of patients grows larger and several people become critically ill over the course of several minutes. She
recognizes that the capacity of the emergency department will soon be overwhelmed. Patients need to be diverted
elsewhere. Rebecca recently completed a terrorism response course at her hospital and is horrified that the need for
that training arose so quickly.

Rebecca has just finished intubating a young woman and is running to check on another patient when the head
physician, Dr. Harrison, announces to the staff that it is time to implement the "capacity triage plan." Rebecca
remembers that this means the staff is only to attend to those patients who are potentially salvageable and must triage
patients by their likelihood of recovery. The patient load, in both numbers and acuity, is beyond the staff's capacity to
care for all of them.

Dr. Harrison says to Rebecca and 2 nurses, "We need to work in such a way that we can save the lives of the greatest
number of patients."

Rebecca looks at the groups of people around the emergency room. She knows that this is the predesignated plan, but
now the patients who are dying and their desperate family members are right in front of her. She wonders if this triage
plan is the right thing to do, especially when she has always been trained to prioritize the care of the most ill patients.
How can she now pass over those patients who seem likely to die? Doesn't this go against everything it means to be a
doctor—just abandoning them like this? What if the dying patients had been her own family members?

Commentary

Rules of triage, the allocating of scarce medical resources in an emergency such as a bioterrorist attack, can engender
moral distress for health care professionals who have to implement them. Yet we need rules such as a "capacity triage
plan," established in advance of emergencies, so that everyone will know how to respond. Otherwise, confusion and
even chaos will reign. Although rules of triage must be formulated with the best medical information available, they
are not merely medical in nature. They also reflect important moral values.
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Triage is one way to ration health care when caregivers cannot meet everyone's needs at the same time and to the same
degree. Systems of triage, whether informal or formal, all have an implicit or explicit utilitarian rationale—they are
designed to produce the greatest good for the greatest number by meeting human needs most effectively and efficiently
under conditions of scarcity. They are structured to satisfy the formal criterion of justice (to treat similar cases
similarly and equal cases equally), and their minimal material criteria for distribution of treatment is some combination
of patients' needs and the probability of successful treatment.

Allocation decisions based on medical utility do not necessarily compromise equal regard for individual persons and
their lives. Each patient counts as 1 and only 1; hence, computing the number of lives that can be saved is compatible
with regarding each human life equally. All patients are treated as equals, even if they receive unequal treatments, if—
but only if—those treatments proceed according to medically acceptable and ethically defensible rules justified to the
public in advance of the emergency.

The perception that health care professionals are abandoning some patients creates a major problem for those patients
and their families, as well as for the professionals involved in triage. In turning away from critically ill patients to care
for others who are less ill, Rebecca feels that she is abandoning both the dying patients and "their desperate family
members." Preparation for a disaster such as a bioterrorist attack means developing medically acceptable and publicly
defensible rules of triage, creating other forms of care for patients, and anticipating the possibility of health care
professionals' moral distress before an emergency occurs. For Rebecca, it is now too late to raise concerns.

Traditional codes of medical ethics did not adequately address situations of triage because of their focus on physicians'
responsibilities for individual patients. In most situations, it is appropriate for physicians to attend first to the worst-off
in the confidence that others can wait their turn without undue burden or risk. It is not surprising, then, that Rebecca
experiences moral distress because of the dramatic conflict between the values that have pervaded her medical
training, on the one hand, and the rules of triage, on the other. It is difficult to shift from assigning priority to patients
who are the sickest to assigning priority to patients who are most likely to survive.

The process of setting the rules of triage should be transparent and open, and all the relevant stakeholders, such as
health care professionals and the public, should offer input in identifying, specifying, and ranking all the relevant
values. Only then will it be possible to ensure public confidence in the fairness of the critical medical decisions that
will have to be made quickly, with little or no time for explanation and justification. Furthermore, in the crisis itself,
professionals must make consistent judgments and decisions based on these rules. Otherwise distrust will erupt and
cooperation will vanish.

Rules of triage need to be fair and to be perceived as fair. Engendering and maintaining the public's trust will be more
likely if the public participates in creating those rules: for instance, determining what to emphasize in medical utility,
deciding which functions and roles are essential if it is necessary to make judgments of narrow social utility (ie, to give
priority to some sick or injured persons because they are needed for important social roles in the crisis), and
establishing whether to have a weighted lottery. Such determinations are not clear-cut, as various simulation exercises
around the country have indicated (eg, Operation Top-off and Dark Winter), and the public should participate in
making them. Furthermore, the issues will become even more difficult if, in order to contain infectious diseases,
quarantine and isolation become necessary. "The public will not take the pill," some have noted, "if it does not trust the
doctor."

When societies confront tragic choices—where fundamental social-cultural values are at stake—they must, as Guido
Calabresi and Philip Bobbit stress in their book, Tragic Choices [1], "attempt to make allocations in ways that preserve
the moral foundations of social collaboration," or, in my language, to create and maintain public trust.

Reference

1. Calabresi G, Bobbit P. Tragic Choices. New York, NY: WW Norton & Company; 1978.
Google Scholar
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James F. Childress, PhD, is Hollingsworth Professor of Ethics, a professor of medical education, and director of the
Institute for Practical Ethics and Public Life at the University of Virginia. He is the coauthor, with Tom L.
Beauchamp, of Principles of Biomedical Ethics, now in its fifth edition, as well as several other books and numerous
articles in ethics. He was a member of President Clinton's National Bioethics Advisory Commission (1996-2001).

The people and events in this case are fictional. Resemblance to real events or to names of people, living or dead, is
entirely coincidental. The viewpoints expressed on this site are those of the authors and do not necessarily reflect the
views and policies of the AMA.

© 2004 American Medical Association. All Rights Reserved.

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